Local, Accessible, Flexible: How the Pandemic Taught Us About Opioid Addiction Treatment and Reducing Overdose Risk

It’s now the spring of 2023. Three years ago, the COVID-19 pandemic arrived in the U.S. and changed life for almost everyone in the country, including people seeking opioid addiction treatment.

In late February, we all watched as authorities in the San Francisco Bay Area went from issuing a public health emergency, to limiting gatherings of over 1,000 people, to recommendations for older and vulnerable populations to stay home. Then, on March 16^th, authorities in six California counties issued shelter-in-place orders, followed by a statewide shelter-in-place order issued by the governor on March 19^th, 2020.

Those events in late February and early March in California set the stage for the entire country.

What most of us did not realize at the time was that all of us – with some exceptions early on, in mostly rural states – would soon experience the same thing as the residents of California. Shelter-in-place orders, the closure of non-essential businesses, virtual school for our kids, mask mandates, and Zoom meetings became the new normal. Essential workers kept going to work, and those who could work online from home stayed home and worked online.

However, this left one group of people in the dark, wondering how they’d get the essential medical treatment that kept them alive: people with opioid use disorder (OUD) who receive medications for opioid use disorder (MOUD) in federally licensed medication-assisted treatment (MAT) programs.

In response to this situation, the federal government, in cooperation with community, municipal, and state partners, eased the strict regulations around medication-assisted treatment programs for people with opioid use disorder.

What Changed During the Pandemic?

When the federal government declared a nationwide public health emergency on March 13^th, 2020, this gave government agencies the authority to issue emergency changes to guarantee the ongoing health, safety, and wellbeing of all U.S. citizens. In response, several agencies acted almost immediately. The Centers for Medicare and Medicaid (CMS), the Substance Abuse and Mental Health Services Administration (SAMHSA), and the Drug Enforcement Administration (DEA) all worked in partnership with state governments to address the unique challenges presented by the COVID-19 pandemic.

We’ll review the changes those agencies made below.

Changes to MOUD and MAT During COVID-19

The U.S. Centers for Medicare & Medicaid Services (CMS) changed rules to allow:

• Expand telehealth clinical services via videoconference
• Expand telehealth services via telephone
• Establish a new Medicare benefit category for opioid addiction treatment

The Substance Abuse and Mental Health Services Administration (SAMHSA) changed rules to allow:

• An increase in take-home doses of methadone for people on MAT
• Telehealth (video or telephone) for delivery of MAT services at OTPs

SAMHSA partnered with the Drug Enforcement Administration (DEA) to change rules to allow:

• Initiation of MAT with buprenorphine via telehealth (video or telephone) for opioid addiction treatment

These agencies changed the rules above because mental health experts, medical experts, and addiction treatment experts all warned that pandemic-related stressors would interrupt access to MOUD dispensing, MAT programs, and other support services. Previous evidence indicated that interruptions to treatment with MOUD and interruptions to MAT programs and recovery support systems for people with OUD increased risk of relapse to opioid use and increased likelihood of fatal and nonfatal opioid overdose.

To prevent these potential negative outcomes, authorities established these new guidelines, despite significant resistance from critics who warned that these measures would have the opposite effect. Opponents thought these changes would increase risk of diversion of MOUD for illicit purposes, which would in turn increase risk of overdose and therefore increase rates of fatal and nonfatal overdose.

Now, three years later, we want to know what happened.

Did easing the restrictions on MOUD for MAT help, as the mental health and addiction experts predicted, or did it cause harm, as critics predicted?

Research: The Impact of Easing Rules for Opioid Addiction Treatment During COVID-19

A study published in the Journal of the American Medical Association called “Receipt of Telehealth Services, Receipt and Retention of Medications for Opioid Use Disorder, and Medically Treated Overdose Among Medicare Beneficiaries Before and During the COVID-19 Pandemic” sought to answer those exact questions.

Before we discuss this study, it’s important to recognize something we hint at in the title of this article. Many of the rule changes relied on the judgment of local providers. Without exception, all of the rule changes included language that empowered decision-making on the part or local mental health or primary care providers. This flexibility allowed for increased access, with the primary check on that access being the informed and educated opinion of the provider, pharmacist, or medical professional serving the individual in question.

Let’s take a look at that study.

Researchers examined the records of 175,778 Medicare beneficiaries with opioid use disorder (OUD) who received OUD-related telehealth services. To determine the impact of expanded telehealth services during COVID-19 related to OUD, MOUD, and MAT, researchers examined records from September 2018 to February 2021. They divided the individual records into two groups:

1. A pre-pandemic group. This group included records from September 2018 to February 2020 for:

• 105,000 people on Medicare of Medicaid
• Gender: 58.1% female
• Race/ethnicity: 79.5% non-Hispanic White

2. A pandemic group. This group included records from September 2019 to February 2021 for:

• 70 538 people on Medicare or Medicaid
• Gender: 57.1% female
• Race/ethnicity: 79.7% non-Hispanic White

All individuals examined were over age 18 and met the clinical criteria for opioid use disorder (OUD) and received telehealth services for medication-assisted treatment (MAT) with medications for opioid use disorder (MOUD) that involved either methadone, buprenorphine, or naltrexone.

Researchers examined the records of these individuals for four main metrics: receipt of any telehealth services, receipt of medication for opioid use disorder (MOUD), retention in MOUD programs, rates of medically treated overdose.

Let’s take a look at the results.

Increasing Access to MOUD During COVID-19: Increased or Reduced Harm?

We’ll report the results for the four main metrics the researcher tracked, in the order we introduce them above. We’ll start with receipt of telehealth services.

Changes to MOUD Regulations During COVID-19: The Results

Telehealth Services

• Received any telehealth service:
  • Pandemic group: 68.6%
  • Pre-pandemic group: 2.5%
• Received OUD-related telehealth services:
  • Pandemic group: 19.6%
  • Pre-pandemic group: 0.6%
• Received behavioral health-related telehealth services:
  • Pandemic group: 41.0%
  • Pre-pandemic group: 1.9%

Those results are instructive. Please observe the staggering differences in receipt of telehealth services utilized before compared to during the pandemic. The percent changes are almost hard to believe: receipt of any telehealth service increased 2,644%, receipt of OUD related telehealth service increased 3,166%, and receipt of behavioral health telehealth services increased 2,057%. It’s safe to say that when telehealth access increased, service use also increased.

MOUD Services

• Received MOUD:
  • Pandemic group: 12.6%
  • Pre-pandemic group: 10.8%
• MOUD dispensing:
  • Pandemic group: 4.0% received methadone from an Opioid Treatment Program (OTP)*
  • Pre-pandemic group: 1.4% received methadone from an Opioid Treatment Program (OTP)

*OTPs are federally licensed facilities that provide MAT with MOUD for people diagnosed with OUD*

The increases here are not quite as large, but they are meaningful: overall receipt of MOUD increased 17%, while receipt of MOUD in official OTPs increased 185%.

Retention in MOUD Treatment

• Pandemic group, buprenorphine:
  • Received buprenorphine more days than pre-pandemic group
  • More individuals reported over 80% adherence to treatment program than pre-pandemic group
• Pandemic group, naltrexone:
  • Received naltrexone more days than the pre-pandemic group
  • More individuals reported over 80% adherence to treatment program than pre-pandemic group
• Pandemic group, methadone:
  • Received methadone more days than the pre-pandemic group
  • More individuals reported over 80% adherence to treatment program than pre-pandemic group

These results are also instructive. Individuals in the pandemic group showed higher rates of treatment retention compared to the pre-pandemic group for people who took buprenorphine, naltrexone, and methadone. These results are important because treatment retention is associated with decreased opioid use, decreased risk of overdose, decreased mortality, and increased social, vocational, and family functioning.

Medically Treated Overdose

• Pandemic group: 18.4%
• Pre-pandemic group: 18.5%
• Receipt of OUD-related telehealth services in the pandemic cohort was associated with lower odds of medically treated overdose
• Compared with participants who did not receive MOUD:
  • MOUD patients who received medication from OTP programs had lower odds of medically treated overdose
  • MOUD patients who received medications from pharmacies had lower odds of medically treated overdose

While the rates of medically treated overdose between the pre-pandemic and pandemic groups are similar, it’s important to recognize the context. Medically treated overdose decreased by 0.01% in the pandemic group during a time period when overall overdose nationwide increased by 30%. That tells us that the services utilized by the pandemic group during the pandemic had a protective effect with regards to overdose requiring medical treatment.

The study authors identify these two outcomes as most important:

1. Retention in medication-assisted treatment programs (MAT) with medications for opioid use disorder (MOUD) improved
2. Likelihood of opioid overdose requiring medical attention decreased

We’ll add that the enormous increase in utilization of telehealth for opioid addiction treatment among people with OUD during the pandemic – and the absence of an increase in negative outcomes – is of equal importance. The pandemic normalized virtual connection in all phases of the lives of people without OUD. For people with OUD, the normalization of telehealth for participation in MAT programs and the receipt of MOUD meant more than a simple change in schedule: it made life-changing and life-saving treatment accessible at a time when no access might have meant increased risk of relapse, overdose, and death.

What This Data Means for Opioid Addiction Treatment Providers

First, we’ll reiterate what we just pointed out above, but in a slightly different way: individuals in the pandemic group used OUD-related telehealth services at 35 times the rate of individuals in the pre-pandemic group.

That’s astounding.

What that means for us, as providers of medication-assisted treatment (MAT) with medications for opioid use disorder (MOUD), is that if we offer telehealth as an option, people will use it – and use it at far higher rates than expected.

However, the study also revealed three additional facts that we need to address, such as:

1. People in the Southern U.S. used MOUD and telehealth less often than people in the rest of the country
2. People who identify as Non-Hispanic Black were less likely to engage in telehealth or engage in MAT with MOUD
3. Over 80% of people with opioid use disorder (OUD) did not use telehealth for OUD

We can sum up with positive takeaways from this study with this phrase:

If we build it, they will come.

In other words, when federal authorities allow local providers the flexibility to increase access to OUD treatment and MAT programs, then outcomes improve: more people will engage in treatment, more people will stay in treatment, and fewer people will experience overdose that requires medical intervention.

But that’s not all: we have work to do in specific areas. This data instructs us to increase our outreach efforts in the Southern U.S., where we own and operate treatment centers in Virginia, North Carolina, and Georgia, and to increase our outreach to non-Hispanic Black communities, which exist in all the states we serve, including California, Georgia, Indiana, Kentucky, New Jersey, North Carolina, Ohio, Pennsylvania, and Virginia.

We’ll end this article with the words of Dr. Carla Shoff, a lead research analyst on this project. In the article “Increased Use of Telehealth for OUD Services During COVID-19 Pandemic Associated with Reduced Risk of Overdose” published by the National Institute on Drug Abuse (NIDA), Dr. Shoff observes:

“The COVID-19 pandemic was an unexpected shock to the US healthcare system, which consequently offered a unique opportunity to investigate the impact of healthcare delivery methods on health outcomes among those who were newly diagnosed with OUD. The findings showed that telehealth improved the receipt and retention of MOUD, suggesting that this method of healthcare delivery may address common barriers to OUD-related treatment such as transportation and perceived stigma associated with OUD.”

 That sums it up, and confirms we’re on the right path. We’ll continue our efforts to reduce stigma and offer the best evidence-based treatment for opioid use disorder available to anyone who raises their hand and says “I need help.”

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Chris Powell

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